Optimal timing and indications for cholecystectomy in cardiac transplant patients

Abstract

Cardiac transplant is performed with increasing frequency as the treatment for end-stage cardiac disease. Although cholelithiasis is more frequent in both pretransplant and posttransplant patients, no standard management approach exists. Because many such patients are cared for outside the transplant center, it is important that general surgeons develop an appropriate strategy to manage this entity. We present our experience with 11 patients from our institution who underwent cholecystectomy before or after cardiac transplantation. In addition, we have reviewed the 76 reported cases of cholecystectomy performed in precardiac or postcardiac transplant patients from centers throughout the world. Any procedure in this patient group requires critical consideration in regard to the timing and type of procedure. Pretransplant patients are well recognized cardiac risks, and posttransplant immunosuppressed patients are at considerable risk for septic complications. Six patients underwent cholecystectomy prior to heart transplant. Five were performed laparoscopically, one as an open procedure. We also report five laparoscopic cholecystectomies in patients after cardiac transplant. One patient in the pretransplant group died 7 days after surgery from an uncontrollable arrhythmia. There were no hemodynamic or septic complications in either group. Current summated experience (87 cases) indicates that the mortality rate for urgent cholecystectomy in the posttransplant group is at least 36%. Because the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic calculi cannot be considered benign. Elective cholecystectomy, laparoscopic or open, is tolerated well both before and after transplant. Given these facts, it seems reasonable to recommend pretransplant screening and posttransplant surveillance for gallstones.(ABSTRACT TRUNCATED AT 250 WORDS)

Asymptomatic Cholelithiasis: Is Cholecystectomy Really Needed? A Critical Reappraisal 15 Years After the Introduction of Laparoscopic Cholecystectomy

“…The aim of prophylactic cholecystectomy is to remove of a possible septic focus that carries a high potential for severe complications in immunosuppressed patients [72,73]. The mortality rate associated with emergency cholecystectomy in patients who have received a heart transplant is high, up to 36% in the review by Begos et al [74]. Finally, cyclosporine and tacrolimus (FK 506), used as immunosuppressive agents, are prolithogenic because of decreased bile salt export pump function [19].…”

Colecistectomia videolaparoscópica em paciente submetido a transplante cardíaco

“…Isto pode ocorrer devido ao efeito tóxico local da droga ou devido a mudanças na composição dos ácidos biliares, podendo ocasionar estase biliar 2 .…”

“…Essa técnica está associada com menores complicações pulmonares pós-operatórias, quando comparada à técnica aberta, com um retorno precoce aos níveis funcionais de pré-operatório, sendo também segura em indivíduos antes do transplante com função cardíaca debilitada 2 .…”

“…Devido aos avanços das técnicas cirúrgi-cas e à melhora das drogas imunossupressoras, como a ciclosporina A 1 , a sobrevida dos pacientes tornou-se maior, com um aumento do número de transplantes cardíacos e de pacientes vivos com corações transplantados 2 .…”

Corrective surgery for idiopathic scoliosis after heart transplantation

“…Indeed, post-transplant immunosuppressed patients are at a higher risk for septic complications that may compromise their life [13]. While there are published reports concerning urgent surgical treatment for acute cholecystitis or diverticulitis in such patients [2,9,12,13,18], there Abstract Cardiac transplant surgery is being performed with increasing frequency as a treatment for endstage heart disease. In addition to the well-known post-surgical problems of rejection and infection, these patients may present at a future date with other medical problems which require surgical treatment, including orthopaedic pathology.…”